Why Were Doctors Afraid to Treat Rebecca McLester?

By Gretchen Reynolds

Published: April 18, 2004

The pediatrics ward at SwedishAmerican Hospital in Rockford, Ill., was busy last June 20, its 10 or so patients suffering from the usual ailments of the young. Linda Wildey, the director of women and children's services at the hospital, was looking forward to the end of her workweek when she received a visit from the manager of the hospital's pediatrics department. A 10-year-old girl was heading for SwedishAmerican's emergency room, and she was suspected of having monkeypox.

''Monkeypox,'' Wildey recalled during an interview in March. ''I could hardly believe I was hearing the words 'Rockford' and 'monkeypox' in the same sentence. It was'' -- she fumbled for a moment -- ''it was shocking.'' Wildey's understanding of the disease was limited. She knew only that it was contagious and that it was nasty. More dismaying was that she and the hospital's chief medical officer, Dr. Kathleen Kelly, slowly realized that finding someone in the pediatrics department to treat the girl was going to be difficult. The small nursing staff could ill afford to dedicate someone full time to caring for the child -- as would be necessary for quarantine. The bigger problem, however, was that none of the nurses, including Wildey, had a recent smallpox vaccination, which was recommended for safe treatment of monkeypox. The more they talked, the more resigned Wildey became. At last, she took a deep breath, sighed and told Kelly that, as head of the unit, she'd agree to be vaccinated that afternoon, and then, since the shot provided quick immunity, would assume the child's care, single-handedly if need be. ''I couldn't ask anyone else to do it if I wasn't going to step up to the plate with them,'' she told me. ''It's my job.'' But as she set down the phone and squeezed her eyes shut, she grimaced slightly. She later recalled thinking, ''My husband will not be happy.''

For the past generation, few doctors and nurses in the Western world have worried much about their profession killing them. But with the appearance of AIDS and SARS, a new medical generation has begun to wrestle with old questions. When an unfamiliar and infectious disease stalks through your city, must you treat the affected patients? What are the consequences if you do? And if you don't?

Monkeypox, as everyone at SwedishAmerican soon learned, is a close relative of smallpox. Both viruses, part of the orthopox family (which includes camelpox, cowpox and gerbilpox), can cause high fevers and scarring lesions. Both can be lethal. But unlike smallpox, which essentially was eradicated by a global vaccination campaign of the 1960's and 1970's, monkeypox thrives in parts of western and central Africa. It was first isolated in monkeys in the 1950's, which is how it earned its name. Its preferred hosts are squirrels, mice and other small rodents. Occasionally it jumps to man. It can then pass from person to person. Several hundred human cases of monkeypox were identified in Congo in the 1990's. Up to 10 percent of the infected die. But the disease had never been seen outside of Africa. Then last spring, for the first time in history, it leaped borders, landing in the United States as a hitchhiker in the glands and secretions of one or more Gambian giant pouched rats, 18 of which, shipped to Texas from Ghana, were destined for Phil's Pocket Pets, in suburban Chicago.

The American market in such exotics is small but growing. It's also insular and unevenly regulated and thrives on the novel. Among aficionados, the 5- to 10-pound Gambian rat has a scruffy chic (unlike in Gambia, where villagers eat them). At Phil's Pocket Pets, the rats settled in next to two recent shipments of prairie dogs. Health authorities say that at least one sick Gambian rat infected Phil's prairie dogs.

One of the prairie dogs wound up as a pet in the home of Eric and Amy Boonos of Rockford, who already had two. Their 10-year-old daughter, Rebecca, liked to wriggle her fingers through their cage, giggling as the animals licked and nipped. But the new pet soon died. Then the Boonoses learned that sick prairie dogs were associated with monkeypox. Public health officials seized the two remaining pets and found they had monkeypox. They monitored the Boonoses and, by the middle of June, Rebecca developed a spiking fever and was covered with ugly, pus-filled sores.

That's how monkeypox arrived in Rockford. Over the course of last summer, 72 cases of monkeypox would be suspected in the Midwest, and 37 would be confirmed.

By the time Rebecca McLester (who bears her mother's maiden name) was on her way to the hospital last June, there was plenty of low-level chatter about the case in the emergency department. The chatter soon rose to a hum. The Health Department had called ahead to alert the hospital to the girl's imminent arrival and to her probable diagnosis. The hospital staff believed, as Kelly later put it, ''that monkeypox could be contagious between people, and that it had a fairly high death rate in Africa.''

Rebecca, over the objections of her worried parents, was asked to remain outside the hospital, sitting in a wheelchair in the parking lot as Kelly and her colleagues rushed to secure the E.R. against infection. They prepped a reverse-airflow isolation room, with fans that would suck in air when a door was opened, preventing germs from escaping. Several of the E.R. doctors had smallpox shots before 1972, when routine immunization stopped, but none had a recent booster. This created a problem. Experts with the Centers for Disease Control and Prevention in Atlanta believed that vaccinations from decades ago would provide only limited protection. (Ten of the people who developed monkeypox had childhood smallpox shots.) So Kelly, who was vaccinated more than 30 years before, pulled on a gown, mask, goggles and booties and, along with the emergency-room physician, prepared to see the girl herself. ''I wanted to show the staff that it was probably O.K.,'' she recalled. ''Plus, I was curious. I was thinking, So this is what smallpox looked like.'' Once she had determined firsthand the nature of the case, she would be able to assemble a team to care for the girl.